OPTIMUM CHOICE OF THE CAROLINAS (OCCI)
Updated 11/00

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background Information	OCCI received its HMO license from the NC Department of Insurance and commenced business on July 12, 1995. It is a for-profit corporation, owned by Mid Atlantic Medical Services, Inc. a Maryland corporation.
Type of HMO	OCCI operates as an IPA model HMO. That means that it contracts directly with physicians in the community or with networks of physicians (IPA/network model).
Type of Products	OCCI’s most commonly purchased HMO plan is a "gatekeeper" product. In a gatekeeper system, you must choose a primary care provider who is responsible for managing all your care. For example, your primary care provider would be required to refer you to a specialist, or authorize a non-emergency admission to the hospital. OCCI also offers a point-of-service option and a "direct access" product.
Accreditation	OCCI has not been accredited by an external accreditation organization. Not all health plans seek accreditation. The accreditation process is very expensive and some plans choose not to participate. This does not necessarily mean that OCCI is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	OCCI offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group"), Medicaid, or Medicare recipients, although some Medicare beneficiaries may have supplemental HMO coverage through their employer.
Counties in which HMO has an Active Presence	OCCI has at least 25 commercial (group) HMO members at the end of 1999 in the following North Carolina counties: Alamance, Cabarrus, Camden, Cleveland, Currituck, Dare, Davidson, Davie, Durham, Forsyth, Gaston, Gates, Granville, Guilford, Harnett, Lincoln, Mecklenburg, Orange, Pasquotank, Perquimans, Person, Randolph, Rockingham, Rowan, Stokes, Surry, Union, Vance, Wake and Yadkin.
Customer Service Number	1-800-347-1965
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: All medically necessary PCP, medical, and surgical specialty services (i.e. anesthesiologists, pathologists, surgical assistants, and radiologists). Room and board in semi-private room. Private room covered when medically necessary. General nursing care. Meals (special diets when medically necessary). Use of operating room and related facilities. Use of intensive care unit and services. Hospital-based physician care. 60 days of skilled nursing services. Limits: Services must be performed or authorized by PCP. Skilled nursing services received in an acute care hospital setting count towards the 60-day per year limit for skilled nursing care. OCCI will notify the member when skilled nursing services have commenced in an acute care setting. Excludes: Personal comfort items such as television or newspapers.
Outpatient Services		Covers: All medically necessary PCP, medical, and surgical specialty services (i.e. anesthesiologists, pathologists, surgical assistants, and radiologists). Outpatient diagnostic services and X-ray services for members who are ambulatory. Cost Sharing: Copayments may apply.
Emergency Care		Covers: Participating provider: Covers medical services from a participating provider needed to treat an emergency until the condition is stabilized. You do not need prior authorization to obtain emergency services. Non-participating providers: Covers emergency services from non-participating providers and facilities if the delay caused by being taken to a participating provider could reasonably be expected to cause the member’s health to worsen. Cost Sharing: Copayments apply. The copayment will be waived if immediately admitted to the hospital. Notification Requirements: You should call OCCI to let them know about the emergency services you are receiving. OCCI may not be required to cover the medical services if you fail to notify OCCI about your emergency services. Excludes: If you seek care in the emergency room for a condition that was determined not to be a medical emergency and was not authorized by your PCP, you will be responsible for payment of the emergency room and any associated bills.
Urgent Care		Covers: Urgent care within the service area. Outside Plan Service Area: If a condition requiring urgent care develops while you are outside the service area, you should seek care from a local doctor or hospital emergency room if necessary. You should notify your PCP prior to receiving services whenever possible to ensure coverage. Care provided outside the service area will be covered only if OCCI determines that the member can not reasonably return to a participating provider or hospital. Cost Sharing: Copayments apply.
Ambulance		Covers: Medically necessary ambulance and special transportation services such as helicopter or airplane when medically necessary.
Care for Students Outside of Service Area		No specific provisions.
Non-Urgent Care Outside of Service Area		Excludes: Non-urgent care outside of service area unless authorized in advance by OCCI or by the member’s PCP.
Professional Services
Professional Services (general)		Covers: Routine office visits, pediatric and well baby care, routine physicals, eye refraction exams, hearing and vision screening exams. In general, covers all medically necessary PCP, medical, and surgical specialty services (i.e. anesthesiologists, pathologists, surgical assistants, and radiologists). Cost Sharing: Copayments apply.
OB/GYN		Covers: OB/GYN services. A referral is not required for services of participating obstetrician/ gynecologist for females age 13 or older related to female reproductive system and breasts. Cost Sharing: Copayments apply.
Diagnostic Procedures		Covers: All authorized diagnostic treatment, lab and X-ray services. This includes radiology, electro-cardiography, electro-encephalography, radiation therapy, and chemotherapy.
Therapeutic Treatment Services		Covers: radiation, chemo-therapy, and respiratory therapy.
Allergy Testing and Treatment		Covers: Initial allergy consultations, including skin testing and physician services. Cost Sharing: Copayments apply.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Well child care and periodic health assessments considered medically necessary. Cost Sharing: Copayments apply. Excludes: Physical examinations for employment, insurance, school, camp, travel, or governmental licensure, unless such exams can be obtained within the limits of the periodic health assessment.
Immunizations		Covered. Excludes: Immunizations for foreign travel.
Preventive Clinical Services		Covers: Mammograms, pap smears, and PSA (as required under state law).
Other Health Promotion/ Disease Prevention Activities		Excluded.
Diabetic Treatment		Covers: Medically necessary diabetes outpatient self-management training and educational services used to treat diabetes.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Prenatal care, delivery, prenatal, and postnatal care arising from pregnancy or resulting in complications of childbirth and miscarriage. Coverage for deliveries includes a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean sections. Also covers ordinary nursing care, childbirth education classes, and midwife services if at an accredited birthing center. Cost Sharing: OCCI will reimburse $50 for childbirth education classes. Copayments may apply. Excludes: Maternity services provided outside the service area in the last trimester , unless authorized by the participating provider or OCCI.
Family Planning		Covers: Examinations, insertion and removal of intrauterine devices (IUDs), Depo Provera, and Norplant, prescriptions for birth control methods, and genetic counseling (when medically necessary). Also covers male or female surgical sterilization. Cost Sharing: 50% copayment applies for Norplant. Excludes: Reversal of voluntary sterilization.
Abortion		Covers: Abortions if medically necessary. Excludes: Abortions which are not defined as documented fetal abnormalities and/or endangerment of the life of the mother if the pregnancy were completed.
Infertility Services		Covers: In vivo fertilization, infertility studies, including testing, medical advice, instruction and treatment to cover any physical abnormality or illness discovered as a cause of infertility, in accordance with medical practice. Limits: Artificial insemination is covered for a maximum of six (6) cycles. Cost Sharing: Copayments may apply. Excludes: Drugs whose primary purpose is the treatment of infertility, except clomiphene citrate (CLOMID). Also excludes in vitro fertilization, embryo transplants, harvesting of ovum or ova, and costs associated with donor sperm and the storage of sperm used for artificial insemination. Excludes reversals of voluntary sterilization.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Services for treatment of psychiatric conditions that can be significantly improved through crisis-oriented intervention and follow-up therapy. Hospitalization, including services of physicians and other health professionals. Room and board, medications, injectibles and medical supplies. Inpatient psychiatric treatment including individual, group, and family therapy. Psychiatric hospital care and nursing care. Shock therapy. Drug therapy. Involuntary admission, when deemed necessary by the evaluating psychiatric physician. Limits: Services must be provided by PCP or by referral from PCP. Once referred by the PCP, the member will be evaluated by a Psychiatric Physician. Group therapy is covered when prescribed by the treating psychiatric physician for care of specific symptoms. Member is also limited to one individual psychotherapy session and up group session per hospital day, unless medically necessary and authorized by OCCI. Members are limited to a maximum of 30 days inpatient services. Cost Sharing: Copayments apply. Excludes: Confinement, treatment, services or supplies related to mental retardation and/or mental deficiency Special education, counseling, therapy, confinement, treatment or services related to learning disabilities or behavioral problems. Treatment for organic mental disorder when the disorder is due to permanent brain dysfunction. Treatment related to autism and treatment of pervasive development disorder. The assessments for these disorders are covered. Conditions that are determined by a psychiatric physician to be untreatable, or untreatable through crisis-oriented intervention therapy. Psychiatric intermediate or residential care. Also services in a psychiatric residential facility are excluded. Psychoanalysis.
Mental Health Outpatient		Covers: Services for treatment of psychiatric conditions that can be significantly improved through crisis-oriented intervention and follow-up therapy. Diagnostic evaluation. Individual, group, and family therapy. Limits: Services must be provided by PCP or by referral from PCP. A missed appointment will be considered a visit unless the provider was notified in advance. Members are responsible for the payment of missed visits. Members are limited to a maximum of 20 visits per year. Cost Sharing: 50% copayment applies. Excludes: Conditions that are determined by a psychiatric physician to be untreatable, or untreatable through crisis-oriented intervention therapy. Psychiatric therapy or psychological testing on court order or as a condition of parole. Psychiatric or psychological evaluation that is primarily for legal or administrative purposes, such as disability determination or security clearances purposes. Court appearances by a mental health provider. Testing for specific learning disabilities, intelligence, or for career aptitude and interests. Confinement, treatment, services or supplies related to mental retardation and/or mental deficiency Special education, counseling, therapy, confinement, treatment or services related to learning disabilities or behavioral problems. Treatment for organic mental disorder when the disorder is due to permanent brain dysfunction. Treatment related to autism and treatment of pervasive development disorder. The assessments for these disorders are covered. Psychoanalysis. Marriage counseling, psychotherapy and other consultations done by telephone, or sexual therapy.
Substance Abuse Inpatient		Covers: Inpatient treatment services in a hospital or licensed or certified facility. Partial hospitalization services in a hospital or licensed or certified facility when provided by a participating provider. Limits: To be covered, treatment must be arranged through appropriate referral by the member’s PCP and must be medically necessary. The condition must also be treatable. Care and treatment are subject to a maximum dollar amount per benefit year ($8,000) and lifetime ($16,000). Cost Sharing: A deductible and coinsurance may apply.
Substance Abuse Outpatient		Covers: Outpatient treatment services in a hospital or licensed or certified facility. Outpatient treatment services provided by a participating physician or other licensed and qualified health practitioner. Limits: To be covered, treatment must be arranged through appropriate referral by the member’s PCP and must be medically necessary. The condition must also be treatable. Care and treatment are subject to a maximum dollar amount per benefit year ($8,000) and lifetime ($16,000). Cost Sharing: A deductible and coinsurance may apply.
Prescription Drugs and Medical Supplies
Prescription Drugs		Excluded, unless purchased through a supplemental policy. With the purchase of a rider, Covers: Prescription drugs that are: Medically necessary. Obtained through a participating pharmacy (except in a medical emergency or out-of-area urgent care situation). Prescribed by a participating provider (except in a medical emergency or out-of-area urgent care situation). Provided while the person is a member. Not specifically excluded in the rider. Limits: Certain products require prior authorization. The following dispensing limits apply: Maximum 31-day supply (unless adjusted based on manufacturer’s packaging size) A 3-cycle supply of oral contraceptives Maximum 90-day supply of maintenance drug products Cost-sharing: Copays apply. An extra charge applies when the member requests a brand name drug and a generic substitute is available. Excludes: The prescription drug rider excludes the following: Experimental drug products. Over-the-counter drugs. Injectable drugs (except Depo Provera, and other drugs that can be self-administered or injected subcutaneously.)
Blood		Covers: Administration of blood and blood products. Excludes: Blood products, artificial blood products, and biological serum.
Medical Supplies		Covers: Medically necessary supplies. Cost Sharing: 50% copayment for supplies. This copayment is waived if the supplies eliminate a hospital admission Excludes: Supplies that are provided for experimental, investigational or cosmetic purposes.
Insulin and Diabetic Supplies		Covered. Cost Sharing: Copayments may apply.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)		Covers: DME such as oxygen, oxygen equipment, wheelchairs, diabetic equipment, and other medically necessary equipment for use in the member’s home. Limits: OCCI reserves the right to determine rental, purchase or repair of DME. Coverage for home oxygen must be: Certified by the prescribing provider that the results of recent arterial blood gas and/or oxygen saturation tests on the patient (on room air if possible) indicate hypoxemia. Such tests must be approved by OCCI. Cost Sharing: 50% coinsurance for all DME . This copayment is waived if the DME eliminates a hospital admission.
Prosthetic Devices		Covers: Orthopedic devices, braces, and prosthetic devices medically necessary to substitute for body organs, and artificial limbs and eyes. Excludes: Penile devices. Medical and first aid supplies that can be directly purchased by the member.
Orthotic Devices		Excludes: Orthotic devices and shoes.
Rehabilitative and Habilitative Services
Physical Therapy		Covers: Medically necessary and treatable short-term physical therapy. Services covered to restore an individual’s loss of function due to an injury, or sickness. Limits: Therapy is limited to conditions which are subject to significant improvement in the member’s condition. Rehabilitative therapy is limited to a combined treatment period of 60 days per condition. For inpatient rehabilitative services, one day equals one visit. Cost Sharing: Copayments may apply.
Occupational Therapy		Covers: Medically necessary and treatable short-term occupational therapy. Services covered to restore an individual’s loss of function due to an injury, or sickness. Limits: Therapy is limited to conditions which are subject to significant improvement in the member’s condition. Rehabilitative therapy is limited to a combined treatment period of 60 days per condition. For inpatient rehabilitative services, one day equals one visit. Cost Sharing: Copayments may apply.
Speech Therapy		Covers: Medically necessary and treatable short-term physical therapy. Services covered when necessary to correct an impairment of organic origin due to an injury or sickness, or following surgery to correct a congenital defect. Limits: Therapy is limited to conditions which are subject to significant improvement in the member’s condition. Rehabilitative therapy is limited to a combined treatment period of 60 days per condition. For inpatient rehabilitative services, one day equals one visit. Cost Sharing: Copayments may apply. Excludes: Therapy needed to correct a problem from a functional nervous disorder, such as stuttering or stammering.
Pulmonary Therapy		Covered.
Chiropractic		Covers: Medically necessary and treatable short-term chiropractic services. Services covered to restore an individual’s loss of function due to an injury, or sickness. $500 maximum per member per year. Cost Sharing: 50%
Cardiac Rehabilitation		Covered.
Other Therapy Services		Excluded.
Skilled Nursing Facility		Covers: All medically necessary PCP, medical, and surgical specialty services (i.e. anesthesiologists, pathologists, surgical assistants, and radiologists). Limits: Coverage is limited to 60 days per benefit year. Skilled nursing services received in an acute care setting count towards the 60-day per benefit year limit. OCCI will notify the member when skilled nursing services have commenced in an acute care setting. Excludes: Custodial care.
Home-Based Services
Home Health		Covers: Medically necessary intermittent home health services when authorized by the member’s PCP and pre-approved by OCCI. Includes the services of registered nurses, licensed practical nurses, home health aides, and therapists Limits: Home health services limited up to 35 hours week for a period not to exceed 21 days. Cost Sharing: Copayment for a home visit by a PCP, specialist, or affiliate provider will apply. Excludes: Custodial care Convenience items Non-medical services
Private Duty Nursing		Excluded.
Hospice		Covers: Appropriate inpatient or home- based hospice services for a terminally ill member. The participating physician must certify that the patient is in the terminal stages of illness, with a life expectancy of six months or less. Coverage includes supportive services such as inpatient and home based services, and counseling for family members during the member’s illness and bereavement.
Transplants and Dialysis
Transplants		Covers: Kidney, cornea, all non-experimental bone marrow transplants, and liver transplants in children under the age of 18 with biliary atresia. Also covers harvesting of the organ from a non-member donor. Donor expenses: Covers all approved physician and hospital charges for organ transplants and any complications when the organ recipient and donor are both members or when the recipient alone is a member. Costs related to the screening of organ donors will be covered for the actual donor only. Limits: Transplants must be approved by OCCI and performed at a facility approved by OCCI. Transplant evaluations will not be covered if the member does not meet basic screening criteria (e.g. age, weight) for a facility. The use of non-participating facilities must be pre-approved by OCCI. Excludes: Charges associated with complications resulting from the harvesting surgery. Transplants and related services not specifically described in the Evidence of Coverage. If the recipient is not a member, services relating to organ donation by an OCCI member are not covered.
Dialysis		Covered.
Other Services
Dental		Covers: Medically necessary care in the treatment of an otherwise medical not dental condition. Certain medically necessary non-dental oral surgical procedures. Services to provide immediate emergency care for accidental dental injury (traumatic injury resulting from external blow to sound natural teeth or mouth) Treatment for TMJ when it results from a congenital deformity, disease or accident and is medically necessary. General anesthesia for dental procedures of member qualifies. Limits: The maximum amount that OCCI will pay for all non-surgical treatments relating to TMJ disorders is $5,000 per member. Cost Sharing: Copayments apply. Excludes: Orthodontic braces. Crowns, bridges, inlays, partial, and/or full dentures, or false teeth. Treatment for periodontal disease. Removal of impacted teeth. Dental root form implants. Root canals. Cosmetic treatment Routine dental treatment and dental x-rays. Shortening or elongation of the mandible or maxilla. Correction of malocclusion. Surgical orthognatics. Dental care except as related to adjunctive dental care or as provided in a purchased rider. May exclude other dental prostheses or dental devices not specifically listed above.
Vision		Covers: Vision screening examinations. Cost-sharing: Copayments apply. Excludes: Furnishing, fitting, or installation of eyeglasses and contact lenses unless covered by a rider. Also excludes vision therapy and radial keratotomy.
Hearing		Covers: Hearing screening examinations. Excludes: Furnishing, fitting, or installation of hearing aids unless covered by a rider.
Foot Care		Excludes: Routine foot care.
Weight Loss		Covers: Services and treatments that are within standard medical practice policies and are medically necessary. Excludes: Services or supplies for weight reduction or morbid obesity treatment, including surgical procedures such as gastric stapling.
Smoking Cessation		Excluded.
Growth Hormones		Covered.
Alternative Therapies		Covers: Acupuncture and biofeedback. Excludes: Hypnotherapy.
Reconstructive/Cosmetic Surgery		Covers: Reconstructive surgery following mastectomy. Includes reconstructive breast surgery performed on non-diseased breast for symmetry with reconstructive surgery on diseased breast. Reconstruction of the nipple/areolar complex following a mastectomy is covered without regard to the lapse of time between the mastectomy and reconstruction. Also covers surgery when needed to correct a congenital defect. Limits: Requires pre-admission authorization. Reconstruction of nipple/areolar subject to the approval of the treating physician. Cost Sharing: Copayments may apply Excludes: Cosmetic surgery that is not medically necessary.
Non-Emergency Transportation		Covers: Reasonable travel and lodging expenses for a member and the parent or guardian accompanying a minor child for covered services that are performed outside of the service area. Cost Sharing: Member must submit a claim to OCCI with all receipts to receive reimbursement.
Excluded Services
Experimental or Investigational Services		Excluded.
Services Not Considered Medically Necessary		Excluded.
Non-Emergency Services Rendered in the Emergency Room		Excluded.
Commonly Excluded Services		See list of common exclusions
Definitions
Medically Necessary		Meets statutory definition.
Experimental or Investigational		Experimental services are defined as services that are not recognized as efficacious as that term is defined in the Institute of Medicine 1985 Report on Assessing Medical Technologies, or any successor report. From the pharmacy rider: A drug, device, medical treatment or procedure that meets any of the following: It is not recognized, in accordance with generally accepted medical standards as evidenced in authoritative medical and scientific publications, as being safe and effective for the condition for which it has been prescribed, whether it is permitted by law to be used in testing or other studies on human patients. It requires approval by a governmental authority (including the F.D.A.) prior to use, but such approval has not been granted. It is the subject of a written protocol used by the treating facility for research, clinical trials, or other tests or studies to evaluate its safety, effectiveness, toxicity, or maximum tolerated doses. This is specified in the protocol itself or in the written consent form used by the facility. A drug will not be considered experimental if any of the following sources consider the drug appropriate for the particular indication: U.S. F.D.A. U.S. Pharmacopeia Drug Information American Medical Association Drug Evaluations American Hospital association formulary Service Drug Information Medical literature (i.e. scientific studies published in a peer-reviewed national professional medical journal)
Emergency		Follows statutory definition of emergency.
Urgent Care		An unforeseen illness or injury which requires timely medical care to prevent health deterioration.
Other		Crisis-oriented (used in the context of mental health policies and services): Having sudden dysfunctional symptoms that respond to prompt psychiatric or medical intervention.
Primary Care Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider		Any duly licensed doctor of medicine under contract with OCCI or its designee in the fields of Internal Medicine, Family Practice, General Practice, Pediatrics or OB-GYN.
What Happens if Member Fails to Choose a PCP?		If you fail to choose a PCP at the time of enrollment, OCCI reserves the right to assign one to you.
Process to Change PCP		You may change your PCP by submitting a change form or calling the Member Services Department. Changes requested by the 20th of the month will be effective by the 1stt day of the following month. Note: If you have an outstanding specialist referral that was authorized by your previous PCP, you will need to request a new referral from your new PCP.
Referrals to Specialists		Your PCP must provide referrals to a specialist. You may not obtain care directly from them.
Can Specialists Serve as PCP		No.
Non-Emergency Hospital Preauthorization Requirements		Your PCP must perform or authorize a participating provider to perform hospital and institutional services. Second opinion: A member can receive a second opinion if he or she disagrees with a recommended treatment or procedure.
Appeal and Grievance Procedures
Informal Reconsideration		A member may file a complaint informally to OCCI by phoning the member services department at 1-800-347-1965 or 1-919-281-7332. A member's provider may request an informal reconsideration of a noncertification. The request must be made within 10 business days from letter of noncertification. OCCI will render a decision within 5 business days. Note: No time limitations are specified in the Evidence of Coverage.
First-Level Non-Certification Appeal Provisions		Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to OCCI within 60 days of the date of their informal reconsideration, UM or claims decision. Members will receive a response from OCCI within 30 days of OCCI’s receipt of the review request.
First-Level Expedited Appeals		Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
First-Level Grievance Hearings		Follows statutory definition. Note: Members or their representatives must request a first level grievance hearing within 60 days of the incident or claim decision. Members will receive a response within 30 days of OCCI’s receipt of their review request.
Second-Level Grievance Hearings (Covers Second- Level Appeals and Grievances)		Follows statutory definition. Note: Requests for second level-grievance hearings must be made within 30 days of the first-level grievance decision. The second-level review meeting will be held within 45 days of OCCI’s receipt of a request for a second-level grievance review. Member will be notified of the decision within 5 business days of the review meeting.
Second-Level Expedited Appeals		Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
Other Avenues of Appeal		Members can obtain independent information about the appeals process and seek assistance from the N.C. Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes		Limitations of Informal and Formal appeal and grievance Process: The appeal and grievance process does not apply to denials rendered solely because OCCI does not provide benefits for the healthcare service performed or requested, as provided in the member’s Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1998 (Financial Report, # 10)		13,851
Member Months (1998) (Financial Report, #11)		132,083
Average 1998 Monthly Enrollment (Member Months/12)		11,007
Percentage of Change in Average Monthly Enrollment between 1997-1998		68.8%
Five-year Enrollment Trends		1998: 13,851 1997: 7,789 1996: 3,700 1995: N/A 1994: N/A
Percentage of Groups that Disenrolled (December 31, 1997-December 31, 1998)		23%
Percentage of Members that Disenrolled (December 31, 1997-December 31, 1998)		11%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1997 — Dec. 31, 1998)		7%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1997 — Dec. 31, 1998)		0%
Utilization Review Information
Number of Reviews Requested, 1998		2,082
Review Rate per 1,000 Members, 1998		392
Percentage of Noncertifications, 1998		29.78%
Appeal Rate per 1,000 Noncertifications, 1998		59.68
Percentage of Appeals Decided for the Members, 1998		56.76%
Financial Data
Total 1998 Revenues (Financial Report, #6)		$ 14,555,627
Total 1998 Premium per member per month (Financial Report, #5 / #11)		$107.16
Five-year Premium per member per month trends		1998: $107.16 1997: $69.43 1996: $98.59
Medical/Hospital Expenses per member per month 1998 (Financial Report, #7 / #11)		$103.50
Medical Loss Ratio 1998 (% premiums spent on Medical/Hospital Expenses) (Financial Report, #15)		96.6%
Five-year medical loss ratio Trends		1998: 96.6% 1997: 90.2% 1996: 65.8% 1995: N/A 1994: N/A
Operating Profit Margin (Financial Report, #9 / #6)		(32.5%)
Five-year Operating Profit Margin Trends		1998: (32.5%) 1997: (35.5%) 1996: (26.5%) 1995: N/A 1994: N/A
Sources of Information
Source of Information		Optimum Choice of the Carolinas, Inc. , Endorsements to the OCCI Evidence of Coverage 1401211-0700NC; 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on Utilization Review and Appeals and Grievances from NC DOI. RX rider 144327-0100NC.

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